What is a Hospital 'Never Event'?
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I was shocked to read on the NHS England website about the number of such events. https://www.england.nhs.uk/2014/02/surgical-safety/ 255 identified incidences of wrong-site surgery, wrong implant or prosthesis used, or objects being mistakenly left inside patients that were reported in 2012/13 and felt to be caused by a combination of factors.
My colleague Malcolm Johnson from our London office has written a blog about a never event that happened to one of his clients.
A body called the Surgical Never Events Taskforce has made a series of recommendations. These include new standards and systems to improve the safety of surgery in English hospitals. It is appreciated that these events are rare, but even one such event is one too many.
Dr Suzanne Shale, Chair of the Surgical Never Events Taskforce, said: “while surgery is a risky business, it is also possible to make it safer. What we found when we looked at NHS data and international research, is that surgical never events almost always occur as a result of systems that are not safe enough, combining with behaviours that are not safe enough. So as well as making underlying systems safer, we want to make sure that everyone understands how safety is built into systems, and we want to enable everyone – from the front line to the boardroom, including patients – to play their part in upholding safety. And when harm does happen – as, sadly, it will – we want those affected by it to be better supported".
The Yorkshire Evening Post goes in to more detail about specific incidents and hospitals.
It states that 1,188 of these mistakes took place between April 2012 and December last year and includes:
- A woman who had a kidney removed instead of an ovary;
- A man who had a testicle removed instead of a cyst on the testicle;
- A feeding tube put into the lungs rather than the stomach;
- Wrong type of implant used in an operation;
- Wrong blood type in a blood transfusion;
- Some patients have fallen from poorly secured windows.
Dr Mike Durkin, Director of Patient Safety at NHS England, said:
“We are determined to make the NHS the safest healthcare system in the world, and we have made even further strides towards that in the last year, with a new National Patient Safety Alerting System to make sure lessons and warnings can be shared much more quickly, and a new programme of monthly publication of data about never events.”
It is good to hear that NHS England are taking this so seriously and making recommendations to minimise and hopefully prevent such events. In the future I hope that no one will know what a never event is.
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